Hepatitis transmissions pose troubling questions
June 1, 1997 9 minutes read
Hepatitis transmissions pose troubling questions
Reports raise concerns about HBV- and HCV-infected surgeons
Recent reports in the news and the medical literature about possible and documented hepatitis B and hepatitis C surgeon-to-patient transmission have prompted experts to advocate more physician testing to help protect patients, but officials at the Centers for Disease Control and Prevention say they have no immediate plans to change current recommendations for testing or practice restrictions.
In a recent landmark case, researchers in the United Kingdom documented HBV transmission to four patients from four surgeons who did not have the "e antigen" (HBeAg) marker. HBeAg is associated with higher levels of circulating virus, and therefore with greater infectivity. Previous reports of surgeon-to-patient transmission all involved infected surgeons whose serum contained HBeAg, both in the United Kingdom and in North America.1
Both U.K. and U.S. guidelines restrict the practice of surgeons who perform exposure-prone invasive procedures based on the presence or absence of HBeAg.2-4 However, in the United States, an e-antigen-positive surgeon is restricted only if an expert review panel in the surgeon’s state decides restrictions are necessary after considering procedures the infected surgeon performs, surgical technique, skill, and possible medical impairment. Such decisions are made on a case-by-case basis.
While the CDC suggests that surgeons be tested for hepatitis B infection, specifically for the e antigen, surgeons in the United Kingdom are required to be vaccinated and to provide documented proof of immune response to HBV vaccination, and are not permitted to perform exposure-prone procedures if they test positive for HBeAg. (See related story in Hospital Employee Health, January 1996, pp. 1-4.) Currently, carriers in whom HBeAg is not detectable may perform such procedures unless they are shown to be associated with virus transmission. Those who refuse to be tested are regarded as HBeAg-positive and are not permitted to perform surgery.
The recent U.K. report documents four cases of HBV transmission by four infected surgeons whose serum did not contain HBeAg. An investigation ruled out other sources of infection. None of the patients developed fulminant hepatitis, and all recovered completely. All four surgeons remain in medicine, but none are performing exposure-prone procedures.
The report points out that relying on HBeAg as a definitive marker for infectivity may not prevent transmission to patients. Furthermore, amplification of HBV DNA by polymerase chain reaction revealed a "precore mutant" strain that can mask a practitioner’s infectivity.
"It makes the virus behave in an abnormal biological way in that the virus no longer makes e antigen, but it’s still infectious," says J.E. Banatvala, MD, chairman of the U.K.’s Advisory Group on Hepatitis and professor of clinical virology at St. Thomas Hospital in London. "These are rare cases, but what is happening now is that so many people are immunized and tested that we are getting the oddities that are creeping out of the woodwork. We knew we would get mutants, but we didn’t know there was this precore mutant which could result in the e antigen not being made and the infection being transmitted. What we now have to do is find out how common this is."
A longitudinal study could determine the number of carriers who might also have the precore mutant. "When we know what the levels and the risks are from testing the four surgeons’ blood samples we already have, we might then test surgeons who are e-antibody-positive or who had no e antigen and see whether they would actually transmit," Banatvala tells Hospital Employee Health.
Certain consequences could result from such studies. "First, you don’t want to stop a lot of surgeons from operating who haven’t transmitted and who are not going to transmit," he says. "If you have fewer surgeons, the [patient] waiting list lengthens and patients could die."
But Banatvala says that concern must be balanced with the possibility that identifying surgeons with mutant strains of HBV could allow them to be treated with drugs that might reduce their virus levels, such as interferon or lamivudine, and preserve their careers.
While U.K. officials weigh the options and decide how to proceed with the information contained in the report, Banatvala says he is "surprised" that U.S. health officials do not place more emphasis on testing surgeons for HBV infectivity.
"It is surprising for the United States because of the higher profile there of preventive medicine," he notes.
Nevertheless, Craig Shapiro, MD, medical epidemiologist in the CDC’s hepatitis branch, says the agency presently has no plans to recommend restricting the practice of HBV-infected surgeons, with or without the e-antigen marker.
"When new data become available like this recent report, we review it here at CDC and we consult with people outside CDC to determine whether it has any implications or not. We’re still in the process of reviewing the report, but right now we have no feeling one way or another that any recommendations have to be changed. If we feel that it has implications, we would probably have to make some decisions about changing recommendations," Shapiro says.
CDC researchers have observed no cases of transmission from e-antigen-negative surgeons to patients in the United States, he adds.
"We don’t have a sense of how prevalent this precore mutation is among people who are carriers of hepatitis B virus. At least from the outbreaks that we’ve observed in the United States, it doesn’t appear to be that common. All the outbreaks we’ve investigated and read about have been from people who are e-antigen-positive," he explains.
Shapiro admits that cases of e-antigen-negative surgeons infecting patients could go undetected because investigations often are not conducted unless a surgeon infects more than one patient. Also, the decision to investigate the source of an HBV infection is made on the county level, and county health departments decide individually which cases to investigate. While the CDC recommends that counties determine possible sources of hepatitis B infections, there are no explicit recommendations to test surgeons who performed procedures on patients who become infected.
However, a prominent surgeon and lecturer says the U.K. report is cause for concern.
Infections represent striking development’
"This report is the first time we have seen chronically infected individuals who are not positive for the e antigen transmit the virus. That’s a concern because there are estimated to be about 1900 surgeons in the United States who have chronic hepatitis B and about 700 who are estimated positive for the e antigen, so you’re talking about a threefold larger number of potentially infectious surgeons," says Donald E. Fry, MD, professor and chairman of the department of surgery at the University of New Mexico in Albuquerque. "Suggesting that there’s potential infectious transmission from the chronically infected surgeon who may not be positive for the e antigen is a striking new development."
Fry is known for his controversial prediction made publicly during national educational symposia in 1995 that chronically infected U.S. surgeons who are positive for the e antigen will no longer be permitted to perform surgery by the year 2000. He still maintains that conviction. Nevertheless, he says he is even more concerned about occupational hepatitis C transmission.
"With hepatitis B, the issue is clearly that every practitioner who works in a hospital and is potentially subject to blood exposure from patients must be vaccinated. But given no vaccine for hepatitis C and no immediate prospects for a vaccine, all health care workers must avoid blood contact in the health care setting, and that means better practices and better barrier protection," he states.
In addition to the lack of vaccine, there is no postexposure prophylaxis for HCV, and at least 85% of people with HCV infection become chronically infected. Chronic liver disease with persistently elevated liver enzymes develops in an average of 67% of people with HCV.5 In contrast, about 25% of HBV infections become chronic.6
Cases of surgeon-to-patient HCV transmission have been documented. In one such case, two patients in Spain acquired the virus after cardiac surgery, with transmission apparently unrelated to blood transfusions. Because the surgeon had chronic HCV, researchers sought to determine whether he had transmitted the virus to patients. Their investigation provided evidence that he may have transmitted HCV to as many as five of his patients during open-heart surgery.7
Also, a communicable disease report from the National Health Service in London says an unidentified health care worker has been found to be the "probable source" of HCV infection acquired by a patient who underwent cardiothoracic surgery at a London hospital. The report says the incident marks the first time such evidence has been established. About 300 patients who may have been exposed to the HCW are being offered serologic testing through their general practitioners.8
Three hundred patients also are being tested in Vermont after being exposed to a 38-year-old plastic and vascular surgeon with chronic hepatitis C.9 Testing is still under way, and no cases of transmission have been documented so far, says Mike Noble, spokesman for 380-bed hospital Fletcher Allen Health Care in Burlington.
There are no recommendations whatsoever’
"Through routine health care it was determined that he had hepatitis C in March. When he found out, he immediately came forward and stopped surgery. That did not have to be done," says Noble, who adds that the hospital does not have a policy for managing HCV-infected HCWs. "When you look at CDC guidelines, there are no recommendations whatsoever."
The surgeon had been practicing at Fletcher Allen for nearly a year when his infection was discovered. He continues to practice medicine, but does not perform surgery.
Fry says such cases are cause for serious consideration of whether HBV- and HCV-infected surgeons should be permitted to practice.
"I think we have to be concerned that infected surgeons with chronic hepatitis B and C may pose a risk to the patients that they care for. It is something that were going to have to address as a profession at some point in terms of whether the chronically infected individual should in fact practice as a surgeon," he says.
All the publicity related to fears of HIV transmission from HCW to patient have diverted both the CDC and the public from the more real threat of hepatitis transmission, he states.
"There still is no evidence of any kind of HIV transmission from physician to patient, and sometimes people confuse the issue. I’m not sure government needs to be involved, but my opinion is that we will be moving toward a professional posture in the next three to five years that would restrict the surgical practice of surgeons who are chronically infected with hepatitis B and hepatitis C," Fry says. "There has not been as much public response to the hepatitis epidemic as there has been to HIV, and accordingly the CDC has not focused that much attention on it. My guess is that the CDC will respond to public concern about the issue as it grows."
References
1. The Incident Investigation Team and others. Transmission of hepatitis B to patients from four infected surgeons without hepatitis B e antigen. N Engl J Med 1997; 336:178-184.
2. UK Health Departments. Protecting health care workers and patients from hepatitis B: Recommendations of the Advisory Group of Hepatitis. London: Her Majesty’s Stationery Office; 1993.
3. Health service guidelines: Protecting health care workers and patients from hepatitis B. Leeds, England: National Health Service Management Executive; 1993. [Publication no. HSG (93)40.]
4. Centers for Disease Control and Prevention. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR 1991; 40(RR-8):1-9.
5. Centers for Disease Control and Prevention. Hepatitis Surveillance: Issues and Answers. Report No. 56. Atlanta; 1996.
6. Centers for Disease Control and Prevention. Protection against viral hepatitis: Recommendations of the Immunization Practices Advisory Committee. MMWR 1990; 39(RR-2):1-26.
7. Esteban JI, Gomez J, Martell M, et al. Transmission of hepatitis C virus by a cardiac surgeon. N Engl J Med 1996; 334:555-560.
8. Hepatitis C virus transmission from health care worker to patient. CDR Weekly 1995; 5:121.
9. Iyengar S. Disease forces Vermont surgeon to halt practice: FAHC doctor urges patients to get tested for hepatitis C. Burlington Free Press, March 18, 1997:A1.
Hepatitis C Summary Recommendations for Health Care Workers
1. No postexposure prophylaxis is available for hepatitis C; immune globulin is not recommended.
2. Institutions should provide health care workers with accurate, up-to-date information on the risk and prevention of all bloodborne pathogens, including hepatitis C.
3. Institutions should consider implementing policies and procedures for HCW followup after percutaneous or permucosal exposure to anti-HCV-positive blood. Such policies might include baseline testing of the source for anti-HCV and baseline and six-month followup testing of the exposed person for anti-HCV and ALT activity. All anti-HCV results reported as repeatedly reactive by enzyme immunoassay should be confirmed by supplemental anti-HCV testing.
4. No recommendations currently exist regarding restriction of HCWs with hepatitis C. The risk of transmission from an infected worker to a patient appears to be very low. Furthermore, there are no serologic assays that can determine the threshold concentration of virus required for transmission. As recommended for all HCWs, those who are anti-HCV-positive should follow strict aseptic technique and standard (universal) precautions, including appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments.
Source: Centers for Disease Control and Prevention. Hepatitis Surveillance: Issues and Answers. Report No. 56. Atlanta; 1996.
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